It’s pretty easy to diagnose a full-blown eating disorder like Anorexia or Bulimia Nervosa. But more subtle forms of disordered eating are difficult to pinpoint. In our culture there is an obsession with size and weight, diet and exercise--the pervasiveness of disordered eating is astounding. Research suggests that up to 50% of the population demonstrate problematic or disordered relationships with food, body, and exercise. Rates of clinical eating disorders are much lower, estimated from 1% to 3% of the general population.

There are four diagnoses of eating disorders in The Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V), Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, and Eating Disorder Not Otherwise Specified. Specific diagnostic criteria are listed for each of the four diagnoses. However, falling short of meeting these criteria does not mean a person is maintaining a healthy relationship with food and weight. Individuals who demonstrate disordered eating may still be at risk both physically and emotionally.

Defining and recognizing disordered eating is a complicated issue. What are the signs and symptoms of disordered eating? How do you distinguish disordered eating from an actual eating disorder or even from more normative dieting behaviors? And what can be done to treat these behaviors once they become a problem?

Signs and Symptoms of Disordered Eating

Symptoms of disordered eating may include behavior commonly associated with eating disorders, such as food restriction, binge eating, purging (via self induced vomiting or excessive exercise, and use of diet pills and/ or laxatives). However, disordered eating might also include:

Self worth or self esteem based highly or even exclusively on body shape and weight

A disturbance in the way one experiences their body i.e. a person who falls in a healthy weight range, but continues to feel that they are overweight

A rigid approach to eating, such as only eating certain foods, inflexible meal times, refusal to eat in restaurants or outside of one’s own home

Disordered Eating vs. Eating Disorders

What distinguishes disordered eating from a full-blown eating disorder? It is all about degree. An individual with disordered eating is often engaged in some of the same behavior as those with eating disorders, but at a lesser frequency or lower level of severity. However, disordered eating is problematic and to be taken seriously, though the symptoms might not be as extreme as those of a diagnosable eating disorder. Individuals with disordered eating may be at risk for developing a full-blown eating disorder and are more likely to have a history of depression and/ or anxiety, or be at risk for anxiety and depression at some point in the future.

As with other mental health issues, it is important to explore how and to what extent disordered eating is affecting an individual’s daily functioning. Issues to consider include the following:

Concentration and ability to focus-- do thoughts about food, body and exercise prevent concentration or impede performance at work or school?

Social life--is socializing restricted because it might require eating in a restaurant, consumption of foods that are scary or uncomfortable, or disruption of exercise routine?

Coping skills-- Is food consumption and/ or restriction used as way to manage life’s problems or cope with stressors?

Discomfort or anxiety-- How much discomfort do thoughts of food and body cause? Are these thoughts hard to shake and anxiety provoking?

A mental health professional can help to distinguish between disordered eating, eating disorders, and more normative diet and exercise patterns and determine whether you might be at risk.

Preventing and Managing Disordered Eating

Here are some things you can do to prevent or manage disordered eating:

Avoid fad or crash diet--many diets are both too restrictive in terms of both quantity and variety. This can cause a feeling of deprivation and possibly lead to binge eating. It is healthier to adopt a more inclusive meal plan in which all foods are incorporated in moderation.

Set healthy limits on exercise and focus on physical activities that are enjoyable. For example, it’s preferable to take a yoga class instead of staying on the elliptical machine until you burn a certain number of calories.

Throw away the scale--people with disordered eating often weight themselves daily or multiple times per day.

Treating Disordered Eating

The relationship we have with our bodies, as well as how we experience our size and shape is complex emotionally and physically. Difficulties with self-esteem and body image are common among those with and without eating disorders. Psychotherapy can help people understand these complex relationships, achieve body acceptance, and explore the relationship patterns and other psychological issues that contribute to the disordered eating. In addition, a nutritionist, who specializes in eating disorders and adopts a non-diet approach to food and exercise, can also be a good resource, particularly with respect to increasing attention to the body’s natural hunger/fullness cues.

I don't understand why "achieving body acceptance" is necessariy a goal in psychotherapy. People with anorexia nervosa are typically at a very low, dangerous weight, that negatively affects them medically and psychologically. Unfortunately, they often "like" their body in this condition. The last thing we should be doing, therefore, is helping them "accept" their body as it is. Perhaps Ms. Gottlieb could clarify what she means in this post. Otherwise, I'm afraid the post is fairly nonsensical as it relates to anorexia nervosa.

My reference to achieving body image acceptance in this post referred to those with disordered eating, not Anorexia Nervosa specifically. You are correct that individuals struggling with Anorexia would not be encourage to accept or remain at an unhealthily low body weight. In this case, treatment would focus on restoration to a more healthy body weight. Overall, treatment of eating disorders and disordered eating generally involves work on body image issues as well as maintenance of an appropriate body weight.
Thank you for reading and for your comment.

Actually, there is no evidence that treatment for anorexia nervosa generally should involve "work on body image issues" or that such "work" (a vague, ill-defined term) improves outcomes in the treatment of AN.
For children and adolescents who suffer from anorexia nervosa, the leading treatment is Family Based Treatment (FBT) as manualized by Lock and LeGrange. FBT is the model recommended by the American Academy of Pediatrics. It does not involve "working" with children and adolescents on "body image issues."
The modern paradigm, supported by the best available scientific research, is that anorexia nervosa is a neurobiological disorder involving the biological systems governing eating behavior, not a "body image issue." That's one reason why FBT, which targets eating behaviors directly, is the most successful treatment method developed so far, and why "body image" therapies have no support in the research literature and are only speculative and experimental, at best.

Dear Ms. Gottlieb,
Your post says you are on the steering committee of the William Alanson White Institute Eating Disorders, Compulsions, and Addiction Program. The website says that the program "focuses on integrating principles of interpersonal psychoanalysis with other treatment modalities." Can you provide an explanation of what this means? As discussed recently in psychologytoday, the best available research data is showing that psychoanalysis yields extremely poor results in the treatment of eating disorders, with rates of recovery around 10%, probably no better than a placebo or no treatment at all. At the same time, psychoanalysis is extremely expensive, financially, for sufferers and their families. Given this evidence, what is the benefit of "integrating" psychoanalysis with other treatments? The result would appear to be dysfunctional, effectively diluting other treatments that have been shown to be much more effective. I realize it is difficult for professionals who were trained in psychoanalysis to let go, but wouldn't that be in the best interests of the public?

Dr. Gottlieb makes an important point. Many people who do not have eating disorders show disordered eating behavior and a negative or over-focused relationship to their bodies. These individuals are more likely to have diagnoses on either the depression or anxiety axes. It is useful to address their disordered eating differently than those who meet criteria for an eating disorder.
The distinction between an eating disorder and disordered eating is an important one.

Several of your recommendations fly directly in the face of recommendations from the National Weight Control Registry. Let's face it - with over 60% of our population overweight or obese, focusing on "disordered eating" is taking your eye off the ball. People who have successfully lost weight and kept it off have three key behaviors: They continue to count calories at maintenance weight, they exercise regularly, and they weigh themselves regularly. Your behavior recommendations are exactly how to sabotage maintenance of a healthy weight.

I would suggest that if a person has a) a healthy BMI, b) a healthy bone density, and c) for women, regular periods, don't even address "disordered eating."

I read Dr Gottlieb's suggestions as attempting to ask us to think about how psychology and behavior play out in the realms of weight management. If your hypothetical person of stable weight is living in an anxious and compulsive way he or she could use some guidance. We need to address both the emotions/psychological aspects of our patients as well as their healthy weight goals.

For example, it is possible to weigh yourself regularly without owning a scale. If someone is compulsively weighing themselves this is not helping them to monitor there weight.